CLINICAL PATHWAYS DAN SISTEM INA CBG’s CASEMIX

RUMAH SAKIT UMUM DAERAH DOKTER SOEDARSO 2

SMF ............................................................ 3
............................................................... 4
1 TAHUN ........................ 5
Nama Pasien : Umur : Berat Badan : Tinggi Badan : Nomor Rekam Medis :
......................................................................................................................................... 6 ....................................................... 7 ................................................. 8 .......................................................... 9 .......................................................... 10
Diagnosa Awal : Kode ICD 10 : Rencana Rawat :
....................................................................................................................................... 11 .............................................................................................................. 12 ............................................................................................................................ 13
Ruang Rawat/Nomor Kamar : Tanggal/Jam Masuk : Tanggal/Jam Keluar : Lama Rawat : Kelas : Tarif per Hari (Rp.) : Biaya (Rp.) :
................................................. 14 ........................................ 15 ........................................ 16 ..................................... 17 ..................................... 18 ..................................... 19 .............................................. 20
Aktivitas Pelayanan Hari Rawat 1 Hari Rawat 2 Hari Rawat 3 Hari Rawat 4 Hari Rawat 5 Hari Rawat 6 Hari Rawat 7 Hari Rawat 8
Hari Sakit : Hari Sakit : Hari Sakit : Hari Sakit : Hari Sakit : Hari Sakit : Hari Sakit : Hari Sakit :
........................... 21 ................................ ................................ ................................ ................................ ............................... ................................ ................................
DIAGNOSIS
Diagnosis Awal : ................................................................................................................................................................................. 11 Kode ICD 10 : 12
Kriteria Inklusi adalah : 22
 ......................................
Kriteria Eksklusi adalah : 23
1. ........................................
2. ........................................
Ada Penyakit Penyerta : 24
1. ........................................
2. ........................................
Penyakit Utama : 25 ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................
Penyakit Penyerta : 26 ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................
Komplikasi : 27 ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................
ASSESMENT KLINIS
Pemeriksaan Dokter : 28 ................................ ................................ ................................ ................................ ................................ ................................ ................................ ...............................
Visite : 29 ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................
Konsultasi : 30 ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................
Pemeriksaan
Penunjang : 31 ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................
Tindakan : 32 ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................
Obat-obatan : 33
1. Oral : ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................
2. Intravena : ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................
Nutrisi : 34 ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................
Mobilisasi : 35 ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................
Asuhan
................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................
Keperawatan : 36
Pendidikan/Rencana
................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................
Pemulangan : 37
Hasil (Outcome) : 38 ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................
Varians : 39 ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................
JUMLAH BIAYA

1
 CLINICAL PATHWAYS DAN SISTEM INA CBG’s CASEMIX
RUMAH SAKIT UMUM DAERAH DOKTER SOEDARSO 2
SMF ............................................................ 3
............................................................... 4
1 TAHUN ........................ 5
DIAGNOSIS AKHIR 40 KODE ICD 10 12 JENIS TINDAKAN 41 KODE ICD 9 CM 42
Nama Perawat (PPJP) :
1. Utama .................................................................................. .............................................. .................................................................................. ..............................................
.................................................... 43
Nama Dokter Penanggungjawab
Pasien (DPJP) : 2. Penyerta .................................................................................. .............................................. .................................................................................. ..............................................
.................................................... 44
Nama Pelaksana (Verifikator) :
3. Komplikasi .................................................................................. .............................................. .................................................................................. ..............................................
.................................................... 45